Documentation Deep Dive

Compiled by Physical Therapy Products staff

Documentation software has evolved a long way from just simple paper charts with scribbled notes from yesteryear. They now are designed to do all the tasks required to run a successful practice—and feature everything from narrative templates to the ability to ensure claims are processed completely and correctly with the proper billing codes. Consumer demands and the realities of the current practice environment are continuing to drive the evolution of the next generation of documentation software. With this in mind, Physical Therapy Products invited some of the market’s leading manufacturers of documentation software to speak about some of the software’s features that have the most resonance with their customers, and what percentage of customers choose to customize it for their needs. They also share how their software is helping practices to get paid for the services they provide, and what effects they believe that MIPS is anticipated to have on how physical therapy clinics complete their documentation.

Q. What features in your company’s documentation software have had the most resonance with your customers?

A. David McMullan, Casamba: Casamba Clinic’s two key features that resonate well with our customers are 1) Customer-driven evaluation templates and 2) The ability to document on more than one patient at a time. 1) Our customer-driven evaluation templates provide therapists the flexibility to customize the clinical content they need to capture for the patient population based on the therapist preferences and the patient’s presentation. Our templates provide the combination of flexibility, ease of use, and compliance. 2) Casamba Clinic meets the needs of the high-volume outpatient rehabilitation market by allowing the therapist to easily and quickly switch from one patient documented note to another. We understand that it is not unusual to have two, three, or even four patients in the clinic at one time, and all at different stages of their treatment. Casamba Clinic allows our therapy providers to document each patient encounter easily through their treatment progression and quickly switch between each patient’s documentation.

common-sense as they seem to be, include the ability to bring-forward and modify previous sessions notes, the ability to set up macros for phrases that are used repeatedly, and the ability to completely customize evaluations or any other kind of template that the user wishes to create. This trifecta, combined, helps to reduce the time taken to document patient encounters and, more importantly, provides meaningful and easily readable output.

Q. How is your company’s software product helping clinics get paid for the services they provide?

A. David McMullan, Casamba: Our Casamba Clinic product is designed to allow the therapist to focus on the patient. All we ask of our therapy providers is to document the services they provide to the patient, and our Casamba Clinic solution will help ensure the appropriate and correct charges will be applied. Casamba Clinic’s documentation and payor-specific rules engine allow our customers to get paid for the services they provide and that their documentation supports.

Q. What percentage of your clients choose to customize their own templates? What are they typically trying to achieve through customization?

A. David McMullan, Casamba: Over 95% of our Casamba Clinic customers use and customize their own documentation templates. The primary goal our customers are trying to achieve is clinical documentation efficiency that is balanced with compliance. Each customer and their therapy providers have their preferences in both their approach and assessment of the patients they provide care for across the care setting. Casamba Clinic templates enable our customers to document their findings and care plans in a compliant format that is based on their preferred customized template.

Q. The Merit-Based Incentive Payment System (MIPS) for Medicare Part B providers is on the horizon. What effects is MIPS anticipated to have on how most PT clinics do their documentation?

A. David McMullan, Casamba: For most customers that have continued to report the quality measures (formerly known as PQRS), the transition to MIPS will have less of a documentation impact since they are already meeting the quality measures component in their documentation. The most significant effects will result in the need for Medicare Part B Physical Therapy clinics clinical documentation solution and workflows to meet the requirements in Improvement Activities and Promoting Interoperability categories for MIPS. Physical Therapy clinical documentation will need to be more patient-focused and include feedback from patient outcomes and engagement tools. Also, Physical Therapy documentation will be essential in the overall care continuum as our patient’s documentation is shared with other healthcare providers in both the post-acute care and acute care settings. Our Casamba Clinic solution supports the capture and transmission of the quality measures for MIPS today, and we are completing changes that will assist our customers with this transition to MIPS.

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